Vocal Function Exercises Laryngeal Adduction Exercises

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					Vocal Function Exercises
Laryngeal Adduction Exercises
Angie Predmore
Robyn Renwick

• To improve vocal quality

• Increase muscle activity
Laryngeal Adduction Exercises
Pushing/pulling   Holding breath
Glottal attack    Pseudo supraglottic swallow
• used with patients with poor vocal fold adduction (hypo-
• laryngeal trauma (may result in recurrent laryngeal nerve
• neurological diseases
  ▫ PD, MS, closed head injury, stroke, congenital conditions
    such as sulcus vocalis (vocal fold furrow)
• should not be used in patients with voice problems due
  to vocal fold inflammation or mass lesions on the folds
  (i.e. nodules, polyps)
• Pushing and pulling exercises should not be used with
  patients that have uncontrolled high blood pressure
                                               (Ramig & Verdolini, 1998)
• Voice quality
 ▫ Facilitate improved vocal fold closure during voice
 ▫ Helps to treat breathiness, low intensity,
   hoarseness, or overall vocal quality
 ▫ Conditions such as vocal fold bowing and vocal
   fold weakness or paralysis

                                            (Logemann, 1998)
• Swallowing safety / airway protection
• Increase muscle activity in the larynx
• Basic to good laryngeal closure during
• A sequence of these exercises should be
  completed before actual swallowing therapy
 ▫ if laryngeal incompetence can‟t be managed
   quickly by postural assists or teaching the patient
   to voluntarily close their airway
                                             (Logemann, 1998)
• Two sets of exercises
• The series of exercises should be completed five
  to ten time per day for five minutes
• Each exercise should be repeated 5 times before
  moving on to the next exercise in the set
• The whole series of exercises should be repeated
  three times

                                          (Logemann, 1998)
Set 1

Exercise 1:
  Be seated.
  Hold your breath as tightly as possible while
  pushing down or pulling up on your chair with
  both hands for 5 sec.

                                         (Logemann, 1998)
Set 1

Exercise 2:
   Be seated.
   Bear down against a chair with only one hand.
   Produce clear voice simultaneously.

                                         (Logemann, 1998)
Set 1

Exercise 3:
  Repeat „ah‟ 5 times with a hard glottal attack on
  each vowel.

                                           (Logemann, 1998)
Set 1
• Patients should practice this series every day for one
• A follow-up swallow evaluation should be completed to
  assess improvements in airway protection from the
• The SLP and patient can also monitor improvements in
  laryngeal function by listening to clarity and vocal quality.
• If no improvements are noted, the exercises should be
  changed to those in Set 2.
   ▫ This prevents monotony and introduces exercises in a

                                                    (Logemann, 1998)
Set 2
• The series of exercises should be completed five
  to ten time per day for five minutes
• Each exercise should be repeated 5 times before
  moving on to the next exercise in the set
• The whole series of exercises should be repeated
  three times

                                          (Logemann, 1998)
Set 2

Exercise 1:
 Pull up on chair with both hands while
 prolonging phonation.

                                          (Logemann, 1998)
Set 2

Exercise 2:
 Begin phonation of „ah‟ with a hard glottal attack
 and sustain phonation with a clear, smooth vocal
 quality for 5-10 seconds

                                          (Logemann, 1998)
Set 2

Exercise 3:
 Pseudo-supraglottic swallow
 Take a breath, hold it, and cough as strongly as

                                          (Logemann, 1998)
• Improvement should be seen within 2 weeks
• Occasionally it will take 6-8 months with some
  patients to attain adequate airway protection or
  vocal quality
 ▫ these are often those who have had more serious
   conditions (i.e. extended supraglottic

                                           (Logemann, 1998)
• Stemple, Glaze & Klaben (2000) suggested that
  the effectiveness of these exercises depends on
  the degree of vocal fold gap
 ▫ prognosis for improvement is most favorable if a
   light touch closure is evident during the
   videostroboscopic evaluation
• Patient should be monitored closely for signs of
  hyperfunction (Miller, 2004)

                           (Stemple, Glaze & Klaben, 2000; Miller, 2004)
• There is very little research about the use and
  efficacy of laryngeal adduction exercises.
• Since there are extremely few efficacy studies
  concerning vocal fold adduction exercises, few
  SLPs currently use the pushing and pulling type
  of exercises.
 ▫ Yamaguchi et al. (1990)
 ▫ Silverman Voice Treatment (LSVT)
Yamaguchi et al. (1990)
• Cases of glottal incompetence
• Treated by the pushing exercises technique.
• Three patients that had paralysis of the vocal folds or
  sulcus vocalis
• All three individuals improved following voice treatment.
  ▫ Two improved 20 dB (statistically significant increase
    in intensity), and one improved 7 dB (clinically
    significant increase in intensity).
• The Lee Silverman Voice Treatment (LSVT)
  program utilizes intensive high phonatory effort
  exercises in order to increase vocal fold
• It has been documented to have short and long
  term effectiveness for those with idiopathic
  Parkinson‟s Disease.

                                             (Ramig, 1998)
Vocal Function Exercises
• Beneficial to treat
  ▫ Hyperfunction
       Too much laryngeal activity
  ▫ Hypofunction
       Too little laryngeal activity
• Prevention
  ▫ Hyperfunction
  ▫ Vocal symptoms
• Research has demonstrated improvements for
  ▫ Vocal nodules
  ▫ Singers
  ▫ Aging voice
• The laryngeal mechanism, like other muscle
  systems, may become imbalanced and/or

• VFE treat in a holistic manner.

• “Physical therapy” for the voice

                             (Stemple, Glaze, & Gerdeman-Klaben, 2000)
• Increase the bulk, strength, and coordinated
  interaction of muscles

• Improved glottal efficiency

• Improved vocal quality
 ▫   Easy onset
 ▫   Frontal focus
 ▫   Respiratory support
 ▫   Balance respiration, phonation, & resonance

                                (Stemple, 2000; “Vocal function exercises”, n.d.)
• Set of 4 exercises
• Completed 2x each, 2x daily
  ▫ 1x in the morning, 1x in the afternoon

• Complete as softly as possible to
  ▫ Purpose: increase muscular and respiratory effort
    to maintain phonation

                                             (Andrews, 2006)
Step 1: Warm-Up
•       Sustain the vowel /i/ for as long as possible
    ▫     on a musical note F
            above middle C for women and children
            below middle C for men.
                May be modified based on patient‟s vocal range.
•       Goal
    ▫     Dependent on patient‟s airflow volume.
    ▫     Targeted volume is 80-100 mL/s of airflow.
    Flow volume, mL H2O/100 mL H2O = _______
                                   (Stemple, Glaze, and Klaben, 2000; Andrews, 2006)
Step 2: Stretching

  •   Say “Knoll” and glide from lowest note
      to highest note in vocal range.

  •   Goal
      ▫   Complete without voice breaks.
      ▫   Use of the word “knoll” encourages a forward
          vocal focus and an open pharynx.
      ▫   Lips should be rounded and the patient should
          feel vibration on the lips.
      ▫   During this exercise, vocal folds are stretched 2006)
                                 (Stemple, Glaze, and Klaben, 2000; Andrews,
Step 3: Contraction

•   Say “Knoll” and glide from highest note to
    lowest note in vocal range.

•   Goal:
    ▫   Complete without voice breaks.
    ▫   Encourages a forward focus and an open
    ▫   Complements the previous stretching exercise
        by contracting the laryngeal muscles.
                            (Stemple, Glaze, and Klaben, 2000; Andrews, 2006)
Step 4:
Adductory Power Exercise
  •       Voice “Oll” (“knoll” without “kn”) as long as
          possible on musical notes C, D, E, F, and G
      ▫    above middle C for women and children
      ▫    below middle C for men
              modify based on patient‟s vocal range).
  •       Goal
      ▫    dependent on patient‟s airflow volume.
      ▫    The goal is the same as the first exercise with a
           targeted volume is 80-100 mL/s of airflow.
                                   (Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

• Patients track progress on a graph
 ▫ Sustained times
 ▫ Daily variation is expected

• Improvement typically seen within 6-8 weeks

                                   (Stemple, Glaze, and Klaben, 2000)
 Once goals have been met and vocal quality has
  improved, the following weekly program is
   Full program 2 times each, 2 times per day
   Full program 2 times each, 1 time per day (morning)
   Full program 1 time each, 1 time per day (morning)
   Exercise #4, 2 times each, 1 time per day (morning)
   Exercise #4, 1 time each, 1 time per day (morning)
   Exercise #4, 1 time each, 3 times per week (morning)
   Exercise #4, 1 time each, 1 time per week (morning)

                                      (Stemple, Glaze & Klaben, 2000)
Voice Therapy: Clinical Studies (Stemple, 2000)
          Provides a variety of cases in which he has used VFE

 • Hyperfunction                     • Hypofunction
   ▫ 9 year old                        ▫ 71 year old
   ▫ 21 year old                       ▫ 36 year old
   ▫ Improved vocal quality            ▫ Improved efficiency of
       Easy onset, respiratory          breath support for
        support, frontal focus           phonation
       Balance among respiration,
        phonation, resonance         • Treatment of vocal nodules
                                       ▫ 26 year old
 • Prevention of hyperfunction
                                       ▫ Improved vocal quality
   ▫ 53 year old
                                           Overall improvement in
   ▫ Avoid hyperfunction as a               vocal folds
     new, higher pitch is learned          Frontal focus
                                           Increased MPT
Prevention of Vocal Symptoms
• Pasa, Oates, & Dacakis (2007)
 ▫ 37 primary school teachers
 ▫ Ages: 21 to 55

 ▫ Results
      Decrease in vocal symptoms
      Improved vocal quality
      Increased maximum phonation times
• Wrycza-Sabol, Lee, and Stemple (1995)
  ▫ 20 healthy graduate-level voice majors
  ▫ Ages 21 to 55

  ▫ Results:
      Improved glottal efficiency
         Increased airflow rates
         Imporved phonation volumes
         Increased MPTs
Aging Voice
• Gorman, Weinrich, Lee, and Stemple (2008)
 ▫ 19 male participants
 ▫ Ages 60 to 78

 ▫ Results:
    Continuous improvements in MPT
    Improved glottal closure
• Andrews, M.L. (2006). Manual of voice treatment: Pediatrics through geriatrics.
  Thomson: Canada.
• Gorman, S., Weinrich, B., Lee, L., & Stemple, J.C. (2008). Aerodynamic changes as a
  result of vocal function exercises in elderly men. The Laryngoscope, 118, 1900-1903.
• Logemann, J.A. (1998). Management of the patient with oropharyngeal swallowing
  disorders. Evaluation and Treatment of Swallowing Disorders. Pro-Ed: Austin, TX.
• Miller, S. (2004). Voice therapy for vocal fold paralysis. Otolaryngologic Clinics of North
  American, 37, 105-119.
• Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene
  training and vocal function exercises in preventing voice disorders in primary school
  teachers. Logopedics Phoniatrics Vocology 32, 128-140.
• Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech,
  Language, and Hearing Research, 41, 101-116.
• Stemple, J.C. (2000). Voice therapy: Clinical studies. Delmar: Canada.
• Stemple, J.C., Glaze, L.E., & Gerdeman-Klaben, B. (2000). Clinical voice pathology:
  Theory and management. Singular: Canada.
• Vocal function exercises. In Vocology. Retrieved July 13, 2009, from
• Wrycza-Sabol, J., Lee, L., & Stemple, J.C. (1995). The value of vocal function exercises in
  the practice of regimen of singers. Journal of Voice, 9(1), 27-36.
• Yamaguchi, H., Watanabe, Y., Hajime, H., Kobayashi, N. & Bless, D.M. (1990). Pushing
  exercise program to correct glottal incompetence. Annual Bulletin of the Research
  Institute of Logopedics, 24, 223-234.